From early on in my quest to understand the unique challenges mental health professionals face in working with patients at risk for suicide, I've wondered aloud about the things that make us the most nervous. I'm still working my way through a list of questions I posted based on my notes from a series of trainings I delivered across New York State. One that has kept coming up since that time is this one:

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn't need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment. (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment. (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can't recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it's not the fault of the individual at risk that we're set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I've addressed this issue here, here, and here when I've talked about how to manage patients who violate the "social contract" of being a patient. But there's something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest. It can be especially hard if the loosely-connected person only shows up when in crisis.

This won't be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able. I know that this is difficult in the context of productivity demands and limited resources. You can't have 80 people on your caseload who all miss 75% of appointments. But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven't taken the least first step to try ideas you've given. It's easy to find yourself thinking, "Maybe if you came a little more often, you wouldn't be in this position." It's especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn't end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear. It takes courage to keep working with someone who has only one foot in the room--especially when they present with suicide risk. Part of every clinician's brain is occupied with worry under these circumstances--worry about losing a patient, worry about being blamed, worry about being sued. It's hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring--and with doing the right thing. Once you're confident about documentation, you can focus on doing what's best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.

Speaking of nomenclature, I'm increasingly growing mistrustful of the term "protective factors." It sounds very "evidence-based" to refer to "risk and protective factors" when discussing one's approach to risk assessment. However, I've noticed a subtle misunderstanding that has creeped in along with the popularity of these terms. Often, it sounds like some clinicians are thinking of risk and protective factors are two sides of the same coin or--better put--two sides of the same scale and you arrive at a formulation of risk by weighing one against the other. The potential mistake is to think that protective factors "cancel out" risk factors.

Although I have a section called "protective factors" in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, "Launching off point factors." What I mean to convey is that it is probably best to think of "protective factors" as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically "protect" against risk previously identified. A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn't change the risk one bit. These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I'm considering recommending that we get rid of the term "protective factors" altogether because of the danger that it can be misleading. I don't have a great substitute, unfortunately. Best I can come up with right now is "Opportunities for Crisis and Treatment Planning," but I wonder if an ordinary person coming to a section so-labelled would know what it meant. Needs more work.

At a recent workshop I presented, a senior colleague commented that our clinical vernacular needs a more apt phrase than "high risk" to describe individuals whose clinical and historical presentation suggests risk for suicide. "High risk for suicide," he pointed out, sounds like suicide is probable, when in fact the likelihood of suicide in any given "high risk" case is still low in absolute terms. So, I've been struggling to think about an alternative. "Elevated risk?" "Multiple indicators of risk?" I don't know. This is not the only area in clinical suicidology with nomenclature problems, but it's the one I need to figure out right now in order to make some recommendations for documentation standards in our department. If you have any ideas, please leave them in the comment section or use the contact page to email me.

A colleague forwarded me the following excellent question posted to a listserv:

One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment. Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment? How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I'm looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.

the writer is correctly concerned about putting all eggs in the self-report basket. A person at risk who is not stable may not be able to follow through with intentions to get help. It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context

the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about. And it relates as a follow-up question to one that is on that docket, "When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient's agreement to voluntary actions:

Document assessment of reliability of self-report. When assessing and documenting self-report the following should be considered and noted:

past experience, if any with the patient as a reliable reporter or not. “Pt. has reliably followed through on medical decisions and plans in the past.”

evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question. If not, “Pt’s thinking is logical, coherent, and reasonable. Judgment is intact. No indication of impaired capacity to make decisions and follow through with them.”

degree of patient cooperation. Explicitly note that the person volunteered information, though s/he didn’t have to. “The patient has been open, cooperative, and collaborative in the assessment and planning process. There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”

impulsivity. The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself. If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that. “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances..."

Show your reasoning. The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors. This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”

Say what you didn't do. Related to the previous point, it as as important to document the road NOT taken. This shows that you took the situation seriously and considered the full range of options.

A corollary to this principle is to note risks associated with alternative courses of action. “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization. The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”

Document consultation. Much more consultation occurs in primary care than is ever documented. This would be a time to do it. One line is sufficient: “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I'd be interested in feedback and ideas from who employs these principles in their documentation. I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

I've returned from a fascinating series of trips to two New York State psychiatric facilities (St. Lawrence Psychiatric and Pilgrim Psychiatric), as part of a project I'm working on with the Office of Mental Health. I learned a great deal from talking about suicide risk with over 500 clinicians from a variety of disciplines and settings--psychologists, RNs, case managers, social workers, psychiatrists, mobile crisis clinicians, family therapists and others. It would be hard to find a group of professionals with more experience working with individuals at-risk, and the questions, comments, and concerns the participants contributed matched that level of experience.

I have made some notes about issues that were raised by clinicians, and plan to blog my thoughts about these in coming months as I get pockets of time to reflect on my travels. As I have stated before, I think it's important for educational initiatives to map closely onto the real-life concerns of clinicians, rather than simply reflecting content that experts deem important. Here are a few concerns and questions that I hope to think more about when I have time:/

When it comes to hospitalizing isn't it always best to "err on the side of caution?"

Why are we focusing on suicide so much when the people we work with have so many other problems?

Why are we focusing on suicide when it's so rare and most people who die by suicide weren't in treatment when they die?

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Does doing a better job with risk for suicide always mean more work and writing?

Is there anyone for whom it is not indicated to ask about suicidal thoughts?

How often should we do a risk assessment?

What kinds of lawsuits have and have not been successful against clinicians in cases of completed suicide?

Even if we do everything right, can suicide really be prevented?

Along the lines of that last question, several clinicians shared moving stories about ways in which suicide has touched their lives, personally and professionally. It is always so sad to hear about these deaths, and so encouraging to hear that some of the ideas I brought for discussion felt relevant to these experiences.

A big thanks to the professionals at OMH, St. Lawrence, and Pilgrim who supported and hosted me during these trips. And to the clinicians at both facilities who made these trainings so stimulating and enjoyable.

I came across this irreverent, but pretty informative post by the Last Psychiatrist about documentation for patients with suicidal thoughts or behavior. He is writing from the perspective of an acute services physician, but much of what he says applies across settings.

Note that the post has ads embedded in it. Besides being annoying, the ads throw off some of the formatting, so you have to scroll down to read the text.

Warning: This post starts out a bit far afield from clinical work. My ideas about how it ultimately connect back, but they're still forming, so this is definitely a "put on your seatbelt" kind of post.

For some time, I have been following the work and blog of Dave Snowden, founder of Cognitive Edge. Snowden is an scientist, theorist, and organizational consultant at the cutting edge of the Knowledge Management (KM) field. Or perhaps it would be more accurate to say that Snowden is a pioneer and visionary who is try to push KM to an entirely different dimension (call it KM 2.0). I must admit that I am still trying to get a handle on Snowden's thinking (it's broader and more complex than I can yet grasp), but one of the most interesting things to me about his work is that he emphasizes narrative (versus purely numerical) approach to "sensemaking." Snowden and others of his ilk argue that you can learn more useful information, detect more weak signals, capture trends earlier through gathering stories than you can by gathering numbers. Stories show emerging trends. Numbers tell you what has already happened. (For a popular version of this argument see Lori Silverman's provocatively titled book "Wake me up when the data are over: How Organizations Use Stories to Drive Results")

Snowden and another KM guru, Gary Klein, were recently videotaped discussing the methodology (and software) that the Government of Singapore has developed to help them detect terrorist risk, the Risk Assessment and Horizon Scanning (RAHS) system. I found their videotaped discussion fascinating, especially Snowden's critique on the failures of knowledge management (2nd clip on the page). I don't know enough to understand the differences between the perspectives Klein and Snowden offer (and, can't in fact follow all of what either one says), but I listened with great interest to their perspective on how one approaches information-gathering, sensemaking, and decision-making in an uncertain, unpredictable, and unstable environment.

Obviously, clinical sensemaking and decision-making is quite different from government counter-terrorism operations. But I could not help but think of parallels, especially for assessment of suicide risk. Here are a couple of developing (and somewhat random) reflections I had:

We know about statistical risk factors, but how do we do sensemaking with a particular person's set of stories. Clinicians have access to rich narratives, but we generally lack methodologies and technologies for sensemaking that retains complexity and guides decision making.

Traditional documentation (the principal knowledge management system for clinical care), including the diagnostic evaluation reports, usually flatten the richness of stories (by design) into a language that is more technical, linear, and sterile than real life. We usually don't capture stories on their own or track raw data, but rather we move quickly to interpretation and synthesis.

I noted in a previous post that I use mindmapping to teach about suicide risk. In that post, I suggested one benefit might be "it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible." In light of what I'm learning from Snowden and KM, I wonder if mindmapping also facilitates sensemaking from narratives better because it is nonlinear and attempts to replicate connections in human thought patterns.

Apropos of my previous post, Where's the family?...family therapy offers an opportunity for gathering anecdotes from multiple perspectives. Snowden has a KM exercise called "Anecdote Circles," which he uses to help organizations gather information through story. The techniques he uses would be interesting to apply to a family, and to gathering information from family members about suicide risk. This kind of raw data is not available without family members.

Our models and language around risk assessment needs to better reflect how fluid and unstable the phenomena of risk and suicidality really are. The act of suicide is a momentary coalescing of a multitude of snippets and anecdotes and narratives. Reading retrospective case studies of people who died by suicide makes that really clear--all of what we categorize as "risk" comes together in a certain way at a certain point in time. As one of my mentors pointed out to me last week, we can "predict" suicide retrospectively, but it is almost impossible to detect prospectively. As clinicians we want to be sensitive to the snippets, so that we can scan the horizon (a la RAHS) and sense emerging trends, far before the data ever catches up.

As I warned in the beginning, these thoughts are pretty raw, but I'm interested in exploring this intersection more.

I'm trying to think about how to categorize risk factors related to gender, race, culture when presenting about risk and guiding people to make risk formulations. In my initial concept maps, I included "male gender" as one of the "predisposition" factors, following categories offered by Bryan & Rudd (2006). But then when I saw how therapists used this in clinical practice, I noticed that people would list male gender right alongside suicidal ideation or behavior as if one carries risk in the same way as the other. Obviously they don't.

We have factors like race, where risk looks quite different for men and women and over the lifespan (with young black men at greater risk, and older black women much less). Not to mention other unique contours of suicidality among black Americans (Joe et al, 2006). So race is a factor to consider carefully, but not list as a "risk factor" in the same way as others like depression, family history of suicide, past suicidal behavior.

One suicide researcher in our department with whom I shared this dilemma suggested that perhaps demographic and cultural factors are best represented of factors that, if properly considered, decrease likelihood of false negatives (i.e., underestimating risk). That makes sense to me. Being a man, an older adult, or African American doesn't put you at risk of suicide, but if you are working with an older adult male you ought to pay special attention to suicide risk and know that you might be likely to underestimate it. In this way of understanding this category, a full risk assessment could include:

There are no established formats for documenting a formulation of suicide risk. I have taken some steps to standardize this documentation in the clinical service I direct, but it needs further development. I'll be helping our department arrive at a common format. Thankfully, I'll be working with some really bright people who can view this documentation need from a variety of perspectives (compliance/QA, acute services, research). Here are some working principles:

1. Check boxes will not do. We can prompt clinicians with keywords, but like it or not, suicide risk formulation will always need narrative.

2. Our format needs to feel friendly and familiar to clinicians with a wide range of education and clinical experience.

3. The following elements should be present:

specific risk factors for suicide

non-specific risk factors for suicide

clinical data that mitigates risk

protective (or potentially protective) factors upon which to build treatment

summary clinical judgement about (a) chronic and (b) acute/imminent risk (there are some examples of metrics that define "low, medium, or high" or at least provide examples of each)

4. The format should eventually be standardized across our continuum of care.

5. Formulations with anything other than low risk, should somehow be addressed in treatment planning process.

6. We need to provide lots of documentation examples for clinicians to use as reference.

I'd be eager to hear from anyone who has a narrative format that satisfies some or all of these principles.

Primary care physicians are often grouped in as "gatekeepers," who need to be able to ask about suicide, know warning signs, and refer. The tend not to get in-depth training about formulating or documenting risk assessments.

The problem with this "gatekeeper" view is that we don't have the kind of seamless system that allows the primary care professional the luxury to leave the judgment call to a mental health professional. It's not like they are standing at a gate, able to wave a patient on to a mental health professional on the other side. There are barriers to access, patients who refuse evaluations, and the need to make decisions about who warrants intrusive involvement and who does not. These are sophisticated clinical judgments that go beyond "know the warning signs." PCPs have to be able to articulate an evidence-based rationale for allowing a patient to go home with an outpatient appointment versus involving a psychiatric emergency team.

I met with a group of pediatric primary care professionals this week. Our discussion brought this point home to me. They were eager to be trained in true risk formulation and documentation--and felt that these skills would help them feel less anxious about asking about suicide.

There may be some gatekeepers for whom instruction in questions, warning signs, and referral options is enough. But primary care gatekeepers need more.

It's hard enough to assess for suicidal risk, interview, reach a formulation, and develop a plan that matches the risk level. But what do you do when the client does not agree to the plan? It is difficult to manage one's emotions, and difficult to know how to proceed. This is especially true when the recommended plan involves a higher level of care. Do you continue to work with the person in a setting that you have judged inadequate for the needs, or do you somehow insist or refuse to work with the person? How do you ddocument around these decisions?

Here are some initial thoughts I have about this unbelievably challenging clinical dilemma. I hope to articulate more principles and recommendations in future posts and papers, and would love to hear other clinicians' ideas.

1. Articulate and document the rationale for recommendation AND for the treatment decision you make. For example: "I recommended partial hospitalization because the daily therapeutic contact, extensive group work, and focus on stabilization fit Mr. X's needs in this case. I offered this recommendation to Mr. X and explained the potential benefits and risks of following this recommendation. I also explained the substantial risk I see in not pursuing this level of care at this time."

2. Respect the client's freedom, and avoid a power struggle. Most power struggles are born of anxiety. We sometimes do have totake coercive courses of action to protect a patient's safety, but many times we twist patients' arm to manage our anxiety more than their safety. This is not a black-and-white/either-or issue. We do need to honor our boundaries, our ethical/legal obligations, and have a level of comfort in order to work with someone. At the same time, clients with intact cognition (i.e, not psychotic or otherwise impaired from making rational decisions) and who are not at truly imminent risk need to have some latitude about the treatment they agree to participate in. Before drawing a line in the sand, we should be clear (and be able to articulate) why drawing that line is necessary for the patient and for the treatment.

3. If you decide to respect a client's choice that goes counter to your recommendation (a la #2), document the clinical reasons why. If Mr. X refuses my recommendation to go to a higher level of care, I might write: "Mr. X refused the offer of partial hospital; he wishes to continue weekly therapy but agrees to nothing more. I agreed to continue to see him outpatient because (a) our alliance is strong and is a protective factor, (b) Mr. X has benefited from outpatient treatment, even though his acuity level makes him more appropriate for partial, (c) he is not in imminent danger, and (d) Mr. X's cognition is grossly intact; his thought process is logical and coherent, and he is judged to have capacity to make decisions about the treatment he wishes." I'm sure this is not a perfect note (and I'd be happy to hear from others about what you might write), but it captures some of the key elements that I think should be documented.